Step-4 Availability

HHA Hours Available (Check all that apply)

4 Hours (AM)
4 Hours (PM)
8 Hours
12 Hours (AM)
12 Hours (PM)
Live-in

Applying For :

Full Time
Part Time

I Prefer ;

Days
Evenings
I am flexible

Enter Your Available Hours Below

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

Will you work overtime (if required)

Yes
No

If no, please explain

Position Desired

Salary Desired

Date you can start

Have you ever been bonded?

Yes
No

If yes, by whom?

Have you ever been convicted of a crime?

Yes
No

If yes, please explain

Professional Licences

Profession

License No:

Exp. Date:

Verification Date / Person

Have you ever been sanctioned by Medicare / Medicaid?

Yes
No

School / Training Program:

Para-Professional Education:

HHA
PCA

Verification Date / Person

List any foreign language(s) other than English and your skill level.

List any additional information you would like us to consider.

I certify that the information given by me is true and correct and without any omission. I understand and agree that any false statement or intentional omission on this application or any subsequently furnished from constitutes cause for discharge at any time during my employment by At Home Personal Care Services, LLC. (AHPCS)

I authorize AHPCS investigate all statements made in this application. I further authorize AHPCS to make any investigation of my credit, criminal and driving records in connection with this application and anytime thereafter in connection with my employment.

I authorize the references listed in this application, to provide AHPCS will all information concerning my previous employment and any other pertinent information about me that they may have.

I understand that all information obtained during pre-employment screening is held by AHPCS in confidence and will not be released to a third party unless AHPCS is required by law or is specifically authorized to do so by me.

I further understand that if I am hired, I will not have an employment contract and that my employment and compensation can be changed or terminated with or without notice or cause at any time by AHPCS.

AHPCS is an equal opportunity employer. We do not discriminate because of age, race, creed, color, sexual orientation, disability, citizenship status, national origin, marital status, veterans status or the presence of a non-job related medical condition or handicap or any other legally protected status.

Name

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Employment Application Form

Step 1 of 4 - Personal Information

Step-1 Personal Information

Step-2 Education History

Step-3 Previous Work History

Step-4 Availability